Knowledge, attitudes and perceptions regarding human papillomavirus among university students in Hail, Saudi Arabia

Introduction

Human papillomavirus (HPV) infection is the most widespread viral infection of the reproductive tract (World Health Organization, 2016). HPV is a well-known cause of cervical cancer, in addition to cancers of the vulva, uterus, vagina, as well as genitals. It is also identified as causing cancer of oropharynx including the base of the tongue and tonsils (Forman et al., 2012). HPVs are natural pathogens that are passed from person to person through sexual contact. Many HPV genotypes have been categorised as medium- or high-risk ones based on their oncogenic ability in infected cells. There are more than 150 different types of HPV, with about 40 strains known to infect the genital area. HPV types 6, 11, 42, and 44 are non-oncogenic, although others (such as 16, 18, 31, 33, 35, 45, 51, 52, 58, 59, and 68) are known to be cancer-causing (Almughais, Alfarhan & Salam, 2018). Low-risk genotypes commonly cause anogenital warts, while high-risk genotypes are associated with genital cancers, particularly cervical cancers, and, to a lesser extent, endometrial and ovarian cancers (Almughais, Alfarhan & Salam, 2018; de Sanjose, Brotons & Pavon, 2018; Alsbeih, 2014). According to a survey conducted in Saudi Arabia, 2.3% of women in the general population are infected with high-risk HPV16/18 at given time (ICO/IARC Information Centre on HPV and Cancer, 2021). The HPV vaccine was first approved by the US Food and Drug Administration in 2006 (Zhang et al., 2016). Two HPV vaccines are widely available at present, and a couple of vaccines are in the pipeline (Yu et al., 2016). The HPV vaccine, which should be provided prior to the first sexual encounter, has been recommended by the World Health Organization (WHO) as the best way to avoid cervical cancer (WHO, 2013). Men have also been vaccinated against HPV in some countries because the available vaccines have been proven to be effective in avoiding anal pre-cancers and genital warts in both genders (WHO, 2013). According to global reports, 75% of sexually active individuals contract HPV over their lifespan (Matsuo et al., 2015). Consequently, in conservative societies, such as Saudi Arabia, where sexual partnerships are regulated by rigid social and religious laws, the prevalence of HPV is low (Turki et al., 2013; Al-Ahdal et al., 2014; AlObaid et al., 2014). However, in Saudi Arabia, an unprecedented rise in the occurrence of HPV infections has been recorded over the last couple of years, with up to 43% of cervical samples collected from healthy Saudi women being positive for HPV DNA, despite contradictory reports (Turki et al., 2013; Al-Ahdal et al., 2014; AlObaid et al., 2014; Alhamlan, Al-Qahtani & Al-Ahdal, 2015; Bondagji et al., 2013). Approximately 2.5 million cases of vulvar cancer and 13,200 cases of vaginal cancer were recorded globally in 2008 (de Martel et al., 2012). Nearly 60% of vulvar cancer cases and 68% of vaginal cancer cases are thought to occur in developing countries (de Martel et al., 2012). The HPV vaccine is also used in the national vaccination programmes of most developed countries, including Australia, Hungary and the United Kingdom (Yu et al., 2016). When the prevalence of HPV increased in 2014, 84 countries included the HPV vaccine in their national vaccination and immunisation programmes (Yu et al., 2016). The prevalence of HPV, insufficient preventive services, inadequate treatment access, socioeconomic conditions, certain cultural causes and values and opinions about cervical cancer have been established as factors contributing to the occurrence of cervical cancer in women living in various parts of the world (Onon & Kitchener, 1999; Yao et al., 2017; Guan et al., 2012; Richardson, Tota & Franco, 2011). According to the Ministry of Health (MOH) of Saudi Arabia, HPV infections are a significant cause of cancer, particularly cervical cancer, worldwide. Furthermore, in 2014, the MOH of Saudi Arabia reported that immunisations help protect against cancer-causing viruses, such as HPV (MOH, 2014). In Saudi Arabia, there is a scarcity of data on public awareness and comprehension of HPV. Furthermore, few public health programs are geared at increasing young people’ awareness of the symptoms, causes, and preventative actions associated with HPV infection. The major source of HPV awareness among the young population may be social media and some web blogs. There are currently no national efforts in Saudi Arabia to promote awareness about sexually transmitted diseases (STDs) and HPV among adults. As a result, the purpose of this study was to look at university students’ knowledge, attitudes, and perception regarding HPV. The study’s findings are meant to give a baseline understanding of young individuals who may be at risk of HPV infection, allowing public health officials to act if necessary. Studies have shown that social, cultural, and economic aspects are linked to the uptake of HPV vaccines throughout time (Bruni et al., 2016; Gallagher, LaMontagne & Watson-Jones, 2018). In Saudi Arabia, there is limited data on the knowledge, attitudes, and habits of people of various ages and genders when it comes to HPV and its vaccine. As a result, this study looked into the knowledge, attitudes, and practices of bachelor, master, and exchange students at the University of Hail regarding HPV infection and its vaccine. This study can serve policy implications and decision-makers in that they should be aware of the overall level of knowledge among health-care workers and implement educational interventions to address information gap and assist health practitioners in consistently recommending the anti-HPV vaccine.

Materials and Methods

The present cross-sectional study included students enrolled at both male and female campuses at the University of Hail, Saudi Arabia, the only public sector tertiary institution in the region. Data were collected from January to May 2020. To assess the university students’ knowledge regarding HPV and its vaccine, a convenience sampling approach was adapted and a self-administered, previously validated 26-item questionnaire was used with some modifications (Khan et al., 2016). Convenience sampling was used because the target population meet certain practical criteria, such as ease of access, geographic closeness, availability at a specific time, or willingness to participate, are included for the study (Etikan, Musa & Alkassim, 2016). The student sample was distributed mainly into Health sciences and non-health sciences comprising of different schools and faculties where students were registered. Moreover, the sample was also distributed among the students educational level where it was categorized into bachelors, masters and doctoral level students.

Data collection

Registered students from all colleges and departments at the University of Hail, Saudi Arabia, were approached regardless of their age, gender, marital status and educational status. The questionnaire was distributed to all the participants, and as an ethical prerequisite, verbal consent was obtained prior to participation in the study. The quality of the data was checked and revised before it was categorized into various variables. The missing data has been excluded while the included data is distributed as per the data type.

Data analysis

The International Business Machines Corporation (IBM) Statistical Package for the Social Sciences (SPSS) version 20 was used to analyze data. Data were collected from the students through a completed survey questionnaire. Incomplete survey form were excluded from the analysis. Various variables was created in the SPSS to retrieve the data from the complete questionnaire forms to the SPSS software. The relationship between demographic and ordinal responses was assessed using binary and linear regression. Reference group were chosen among the variables which comes at the end and having a maximum number of participants among the dichotomous variables comes in the category of both demographics and ordinal responses chosen by the study participants (Ranganathan, Pramesh & Aggarwal, 2017). Dummy variables were created before the data analysis using binary logistic regression. Once the encoding of all the independent variables as dummy variables was done, the odd ratios and significance of the coefficients were calculated. The key factors that may affect the respondents’ opinions regarding HPV vaccination were identified using a relative importance index (RII) (Eq. (1)) (Elbarkouky, 2012). The item with the value closest to one RII value was rated as the most significant factor affecting the HPV reporting process (Gündüz, Nielsen & Özdemir, 2013).

(1) $$RII={\displaystyle \frac{\sum W}{A\times N},}$$

where W is the weight assigned to each element by the respondents, which varies from 1 to 5 (with 1 indicating ‘strongly disagree’ and 5 indicating ‘strongly agree’); A is the maximum weight (i.e., 5 in this case) and N is the total number of respondents. Regression analysis was then used to classify the variables influencing the respondents’ awareness of HPV vaccination, with gender (ref. male) and field of study (ref. non-health science) being covariates. When assessing the respondents’ answers, a statistically significant value of <0.05 was allocated.

Results

A total of 477 students were approached. Of these, 386 students responded to the survey, with the response rate being 80%. The majority of the respondents (63%) were male, and 332 (86%) respondents were single among the study population. Most respondents were aged 21–25 years (75.6%), followed by 26–30 years (12.7%). Furthermore, most respondents (90%) were undergraduates. A total of 102 (26.6%) respondents were enrolled in pharmacy, 68 (17.6%) in education and 73 (18.9%) in other fields (various fields other than those listed), with lower participation (1.8%) being observed from the fields of physiotherapy and biological sciences (Table 1). Moreover, Bartlett’s test of sphericity used for assessing the content adequacy revealed that the contents were satisfactory and met the study requirements (Khan et al., 2016).

Discussion

The present study assessed how multidisciplinary students at the University of Hail, Saudi Arabia, felt about HPV and what they knew about it. To our knowledge, this is one of the first such studies to be conducted in Hail. Except for a few questions, most respondents had borderline or poor knowledge regarding HPV. Despite being multidisciplinary students, roughly 66.3% of the respondents had never learned of HPV and only around 39.6% knew that HPV infects all genders. Most respondents were unaware that HPV causes cervical cancer, and nearly 45.1% were unaware that HPV infection is uncommon in Saudi Arabia. In a related study conducted in Pakistan (Khan et al., 2016), only 57% of students were aware of HPV, indicating that Saudi students are less knowledgeable about HPV. This lower level of knowledge may be attributed to the fact that non-health science students were more likely to participate in the present study. Similarly, almost 17.7% of participants in a study conducted at the University of Lagos, Nigeria, had learned of HPV and only 19.6% said that HPV causes cervical cancer (Nkwonta, 2018). Furthermore, the awareness of genital warts was lower in the present study than in a study conducted in Lahore, Pakistan; in that study, 52% of university students knew about genital warts (Khan et al., 2016). Inadequate information on HPV in various instructional materials used in cervical cancer awareness programmes in Saudi Arabia may be responsible for the lack of knowledge regarding genital HPV infection and genital warts. In the present study, more than 40% of the respondents knew that the HPV vaccine is not strictly meant for sexually active individuals. Furthermore, 38% of the respondents reported that HPV causes cervical cancer, 26.7% reported that it causes penile cancer, 30.1% reported that it causes genital warts and 14.8% reported that HIV infection is a health problem associated with HPV infection. These results were contradictory to those of a previous study on Columbian students conducted by Piñeros et al. (2013). In Saudi Arabia, there is a lack of information about HPV; therefore, some respondents in the present study thought that it can be avoided by using antibiotics. The present findings highlight the need for a well-designed educational programme on HPV infection in Hail, Saudi Arabia, where there is inadequate awareness of HPV infection and low self-perceived resistance to HPV infection and HPV-related diseases. Another significant finding of the present study is the respondents’ experience with HPV vaccination. The implementation of HPV vaccination is a big move forward, with approximately 49.5% of the respondents in the present study claiming that the vaccine would shield them from HPV. Surprisingly, a handful of respondents who were aware of the HPV vaccine mentioned that they would ask for their healthcare providers’ consent before getting vaccinated against HPV. In a related survey conducted in Italy, 81.7% of respondents mentioned that they would be able to get the HPV vaccine (Di Giuseppe et al., 2008); though a higher percentage of results was reported when compared with the current study results. The effect of HPV educational programmes and the national HPV immunisation programme, which provides free vaccines for girls aged 12 years, may explain the comparatively higher level of vaccine acceptance in Italy.

Conclusion

This study may have policy implications and can serve decision-makers in that they should be aware of the overall level of knowledge among health-care workers and implement educational interventions to address information gap and assist health practitioners in consistently recommending the anti-HPV vaccine. The present findings revealed that respondents at the University of Hail, Saudi Arabia, had poor knowledge regarding the health issues associated with HPV, its preventive measures and its transmission. Nearly a quarter of the respondents were unaware of the availability of the HPV vaccine, while the rest had poor knowledge regarding the risks of recurrence following vaccination. Furthermore, more than 40% of the respondents were ignorant about the prevention of HPV, transmission and problems associated with HPV infection. However, 40% of the respondents said that they would get vaccinated against HPV if their parents approved it, while 56% said that they would get vaccinated if their doctor recommended it. Because both genders are the target of the HPV vaccine, training on HPV infection, related diseases, and prevention methods is required to support the critical role in the prevention of STIs, some of which are linked to the development of cancer. Universities provide a unique opportunity to communicate HPV knowledge to the target audience, and young adults see teachers and trusted clinicians as their preferred sources of information. Improving students’ understanding could have a positive impact on vaccine coverage rates.

Strengths and Limitations

The present study is probably one of the initial studies to discuss HPV health literacy among Saudi students and to provide a clear understanding of students’ attitudes towards HPV. The findings can be used to increase HPV awareness by developing an effective educational strategy. However, the present findings cannot be applied to all students and young adults in Saudi Arabia. The data are more relevant to urban dwellers and trained adults. This study also might not be generalized on the overall population of the Hail region, as the sample population selected was the students of one of the main universities located in the region and it was chosen since it was the only public tertiary institution of the region. Furthermore, the present study did not assess the association between the respondents’ answers and their age and marital status. Further research with a larger sample size is recommended; such efforts would also aid in the development of educational services for various age ranges.

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